Claims that clear.
Members that stay.
Govology delivers data, analytics and operational platforms for Australian private health insurers, restricted access funds and large self-insured organisations. Claims integrity, fraud detection, member analytics, network performance and APRA-aligned prudential reporting — on one auditable platform.
Margins compressing. Risks expanding.
Australian private health insurers operate in one of the tightest margin environments globally — with a regulator (APRA) that expects mature data governance, members who churn at the renewal click, and a claims system designed for processing rather than insight.
Claims leakage you can't quantify
Industry leakage estimates run 3–7% of claims spend. Without proper analytics, the question isn't 'how much are we losing' — it's 'we don't know.'
Member retention modelled with intuition
Renewal decisions are made on broad cohorts. The members at real churn risk — and the ones not worth retaining at price — sit in the data, unseen.
Prudential reporting as a quarterly scramble
APRA reporting assembled from multiple systems with manual reconciliation. The risk: a number that doesn't tie back, audited.
Network performance opacity
Provider network performance is opaque. Outliers in cost, complication rates and patient outcomes get discovered through anecdote, not analytics.
Five disciplines. One platform.
Insurance data work splits into a small number of disciplines that, done well, compound. We deliver them in a sequence calibrated to your portfolio and where the value is most concentrated.
Capabilities for actuarial-grade operations.
Each capability is shaped by the realities of Australian health insurance — APRA prudential standards, the Private Health Insurance Act, MBS and prosthetics list complexity, and the specifics of for-profit and not-for-profit fund operating models.
Claims integrity & leakage detection
Models that flag duplicate claims, miscoded items, billing pattern outliers and provider-level leakage indicators. Recoveries documented and tracked.
Fraud detection
Statistical and ML-based fraud detection across claims, members and providers — calibrated to your tolerance for false positives and embedded in the adjudication workflow.
Member retention modelling
Churn risk scoring, retention propensity, and the action triggers for retention teams. Lifetime value and acquisition cost integrated.
Member segmentation & lifetime value
Behavioural and value-based segmentation that informs product, pricing, retention and acquisition strategy.
Provider network performance
Provider-level cost, complication rate, length of stay and patient outcome analytics — with risk-adjusted benchmarks where data supports them.
Premium & product analytics
Product mix, premium pricing, lifetime health cover loading impact, hospital and extras cohort behaviour.
APRA & regulatory reporting
Continuous APRA reporting and prudential governance evidence — not a quarterly assembly process.
Capital & reserve analytics
Solvency and capital adequacy analytics aligned to APRA prudential standards, integrated with claims and underwriting data.
Aligned to the prudential framework Australian insurers are held to.
Private health insurance in Australia sits inside a defined regulatory framework — APRA, ASIC, PHIO, the Private Health Insurance Act, the Australian Government Rebate. Our data work is built to that framework from day one.
Australian data residency on Azure. IRAP-aligned controls available. Actuarial governance built in.
- APRA prudential standardsData and reporting structured to APRA prudential standards for private health insurers (HPS series and supporting standards).
- ASIC & conduct regulationConduct, complaints and member outcomes data structured to support ASIC engagement and ongoing conduct governance.
- Private Health Insurance ActProduct, premium and rebate handling consistent with the Private Health Insurance Act and related rules.
- Australian Government RebateRebate handling and reconciliation, including tier-based rebate calculations and member income testing.
- Lifetime Health Cover loadingLHC age-at-entry tracking, loading calculations and forty-year reset rules.
- MBS & Prosthetics ListMBS item code analytics and Prosthetics List compliance, with awareness of ongoing reforms.
Built for the sectors we know.
Govology is purpose-built around Australian local government and aged care — sectors where regulatory and stakeholder context shapes every decision.
Private health insurers
For-profit and not-for-profit private health insurers operating in the Australian market — from large nationals to specialist single-state funds.
- Claims integrity, fraud and leakage analytics
- Member retention and lifetime value modelling
- Provider network performance
- Premium pricing and product analytics
- APRA prudential reporting and governance
Restricted access funds & self-insured
Restricted access funds (employer, industry, professional) and large self-insured organisations — including aged care providers running self-insured employee health benefits.
- Member analytics for restricted-access cohorts
- Claims and benefit utilisation analytics
- Self-insurance reserve and capital modelling
- Provider relationship and contract analytics
- Compliance reporting for sponsor and regulator
Connectors to insurance and clinical systems.
We work with the major Australian health insurance, clinical and reference data sources — through versioned, observable integrations.
Questions, answered.
Do you replace our claims system?
No. We work with whatever claims and policy administration system you run — HAMBS, custom platforms, or vendor solutions — and bring claims, member, provider and reference data into a unified analytics platform. Replacing claims systems is a multi-year program; gaining insight from existing data is months.
Is the platform suitable for APRA reporting?
Yes. APRA prudential reporting and continuous evidence is a core deliverable. The data is structured for HPS-series reporting, capital adequacy, and the supporting governance standards — with audit-ready lineage from source to report.
How accurate is fraud and leakage detection?
Detection accuracy is calibrated to your false-positive tolerance and adjudication capacity. We baseline against known recoveries, deploy in shadow mode first, and only move models into production when they're earning their place. The first six months are about calibration as much as detection.
Can this support a smaller restricted-access fund?
Yes. The platform scales from large national insurers down to smaller restricted-access and not-for-profit funds. The analytics that matter — claims integrity, member retention, provider performance, prudential reporting — are the same. The implementation depth is calibrated to scale and complexity.
How is member data protected?
Australian data residency on Azure, ACSC Essential Eight aligned, role-based access, immutable audit logs and data flows designed to Australian Privacy Principles. Member-identifying data is tightly scoped, with analytics typically operating against pseudonymised cohorts where identifiability isn't required.
From quarterly assembly to live insurance operations.
Book a 30-minute discovery call. We'll review your current data and reporting landscape and identify where the highest-value first move is — no commitment.
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